Welcome to Physician's Surrogacy. Thank you for taking the first step in making a difference! Surrogate mothers are very special. We are very excited to review your initial application. Once submitted, you will be contacted by a Surrogate Specialist who will guide you through the intake process. If you have any questions, please feel free to contact us at 858-299-4540.

1.

First Name

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2.

Last Name

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3.

Address

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4.

City

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5.

State

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6.

Zip Code

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7.

What is your primary phone number?

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8.

What is your date of birth?

9.

What is your height?

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10.

What is your weight?

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11.

What is your ethnic heritage? (Check all that apply)

Ethnicity

Mother's Side

Father's Side

Asian:

Black or African American:

Hispanic or Latino:

Native American:

German:

French:

Irish:

Italian:

Pacific Islander:

Cherokee:

Caucasian:

Other:

Other / Mixed

12.

Due to tribal laws, we need to ascertain whether or not you (or any immediate family members) have Native American heritage. Is anyone in your immediate family affiliated with any tribes or reservations?

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13.

Are you currently in a relationship?

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14.

What is your legal marital status?

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15.

What is your citizenship status?

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If Other, please explain

16.

What is your spouse/partner's name? (or n/a if no partner/spouse)

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17.

What is your email?

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18.

What is your spouse/partner's email address? (or n/a)

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19.

How many biological children do you have?

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Please Explain

20.

Total number of pregnancies

Pregnancy Description

Number

Date(s)

Term Delivery:

Pre-Term Delivery:

Spontaneous Miscarriage:

Elective Abortion:

Stillbirth:

21.

How many C-sections have you had?

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22.

A full term delivery is 37- 40 weeks. Have you ever gone into preterm labor and delivered before 36 weeks?

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Please Explain

23.

Your delivery history

Delivery

Own or Surrogacy

Date Of Birth

Vaginal or C-Section

Birth Weight

Number of Weeks Carried

1:

2:

3:

4:

5:

6:

7:

8:

24.

Have you ever had any of the following major complications during pregnancy?

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If yes, please explain

25.

Are you currently breastfeeding?

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Please Explain

26.

What is your current form of birth control?

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How long have you been using this method? Please explain.

27.

Past History of long-acting birth control:

When Started

When Stopped

Depo-Provera Shot:

IUD (Mirena / Skyla / Liletta):

Nexplanon / Implanon:

28.

Have you taken any prescribed anti-depression or anti-anxiety medication in the last 12 months?

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If yes, which medication? Please explain

29.

Do you smoke?

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If yes, how often?

30.

How frequently do you drink alcoholic beverages?

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Will you be able to abstain from alcohol throughout your surrogacy journey?

31.

Past or present history of the following:

Issues

Yes / No

Date Stopped Treatment

Current Issue?

Current Treatment (or n/a)

Diabetes:

Heart Problems:

High Blood Pressure:

Ovarian Cysts:

Uterine Fibroids:

Thyroid Problems:

If yes to any above, please explain.

32.

Any major GYN surgeries involving reproductive organs?

Surgeries

Yes/No

Date of Procedure (or n/a)

Ovarian Cystectomy:

Fibroid Removal:

Salpingectomy:

Oophorectomy:

Other (please specify):

33.

Have you had symptoms of migraine headaches during pregnancy that required treatment?

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Please Explain

34.

Have you had asthmatic symptoms during pregnancy that required treatment?

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Please Explain

35.

Have you ever taken medication for gestational diabetes?

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Please Explain

36.

Are you or your partner / spouse currently diagnosed with:

Type of STD

Myself

My Partner

Neither

AIDS:

Genital Warts:

Hepatitis B:

Hepatitis C:

Herpes:

HIV:

HPV:

Syphilis:

Trichomoniasis:

If yes, when were you diagnosed? Were you treated?

37.

Within the last year, have you or your partner/spouse been diagnosed with the following:

STD

Myself

My Partner

Neither

Chlamydia:

Gonorrhea:

If yes, when were you diagnosed? Were you treated?

38.

Have you ever been convicted of a felony?

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If yes, please explain:

39.

Has your partner/spouse ever been convicted of a felony?

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Please Explain

40.

Occupation, if employed

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41.

How did you hear about our center?

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Please Explain

42.

What is your email address for communication with you regarding your pre-screen application?